Bone Cancer Research Trust Strictly Research Grant Applications - - PowerPoint PPT Presentation

CHARITABLE INCORPORATED ORGANISATION (CIO) NUMBER - 1159590

Bone Cancer Research Trust

‘Strictly Research’ Grant Applications

BCRT 10th Anniversary Conference 07/05/2016

Safe surgical margins for Ewing Sarcoma

R Craig, M Gibbons, N Athanasou, T Theologis Oxford Sarcoma Service/NDORMS

If we were to plan our surgical resection for Ewing Sarcoma from the post-chemotherapy scan, would we still achieve a disease free margin?

Study question

Background – Ewing Sarcoma

• 3rd most common primary bone cancer
• 1.5 per million
• Predominantly affects teenagers and young adults
• ~50% of cases affect the long bones of the arms and legs

Typical treatment pathway

Local control

Neo-adjuvant Chemotherapy Surgery Adjuvant Chemotherapy Radiotherapy

Surgery vs radiation

• No randomised studies of surgery vs radiation
• Current practice favours surgery for local control

What are our surgical goals?

• Curative resection as part of multimodal treatment
• Clear margins
• Limb salvage surgery should not compromise survival
• Must be as safe as amputation

Example reconstructions

Clinical case

Ewing Sarcoma: Responsive soft tissue mass

Post-chemotherapy Pre-chemotherapy

Ewing Sarcoma: Responsive soft tissue mass

Post-chemotherapy Pre-chemotherapy

Marginal vs More Radical Approach

Is there surgical consensus?

Tidemark

?

Healthy Tissue Oedema Tumour

Current evidence

• No consensus on the required margin –global variation
• Typical approach 2cm on pre-chemotherapy MRI margin
• Survival not compromised if microscopically clear

Part 1:

Study Plan:

“Proof of Principle”

• Retrospective review
• Quantitative assessment of pre and post chemo imaging
• MRI + PET where available
• Confirm parameters for prospective study

Part 2:

Study Plan

Prospective study

• Quantitative assessment of pre and post chemo imaging
• MRI + PET where available
• Histopathological analysis of selected resection levels
• Actual operative margin
• Measured resection from post-chemotherapy scan
• Expect 2cm margin on pre and post chemotherapy scan

Actual tumour margin Resection from post-chemo scan Resection from pre-chemo scan Actual tumour margin Resection from post-chemo scan Resection from pre-chemo scan

“If we were to plan our resection based on the post-chemotherapy scan, would we achieve a disease free margin?” Study Question

Outcome measures

• Is a 2cm margin based on a post-chemotherapy scan clear of tumour?
• What is the difference between the actual length of resected bone and the new

theoretical resection?

• Would the reconstructive plan be changed by a more minimal resection?

What is the intended benefit?

↑ function ↓ reoperation ↑ Limb sparing ↑ Joint sparing ↑ Growth sparing Reduce resection volume

Which requires safety data from our study

Timeline

June 2016

• Ethics approval
• Collect and analyzeretrospective

study data

July 2016-July 2018

• Prospective study
• Aim to recruit 20 cases
• Collaboration

End 2018

• Completion of data analysis
• Dissemination of results

Dissemination of results

• BCRT
• British OrthopaedicOncology Society
• BOA –Tumoursection
• Submission for open access publication in 2019
• The Bone and Joint Journal (or suitable alternative)

Key messages

• Surgery is only a small part of overall management
• Significant implications for long term function
• Aggressive resection may limit the reconstructive options
• More marginal techniques need to be assessed for safety

Meet The Team

Thank you Any Questions?

R Craig, M Gibbons, N Athanasou, T Theologis